Patient Notification Regarding State-Mandated Reportable Conditions Certain infectious diseases and conditions and the identity of those who test positive for them, are required, by federal and/or state law, to be reported to local or state health authorities by your health care providers, including New Century Lab’s Ordering physicians, University Services, its physicians, staff, and the laboratories that run the medical tests. The time frames and reporting requirements vary according to the disease or condition. These local and state health authorities are considered Public Health Authorities according to the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) which means that they are legally authorized to receive your Protected Health Information (“PHI”). However, both New Century Labs, LLC and these health authorities will not otherwise share or release any confidential information, unless mandated by law or authorized by you in writing.
You understand that if you test positive for any infectious disease or condition on the state’s list of reportable conditions, your test result and your identifying information will be reported to the applicable local or state health authority. Reporting this information does not require your permission or consent. Additionally, you understand that if you test positive for any infectious disease or condition, neither New Century Labs, LLC, nor its staff, University Services, its physicians, staff, or the laboratories that run the medical tests, will treat, prescribe medications, or refer you for medical treatment. It is your sole responsibility to seek and comply with necessary treatment and all required follow-up with your physician or local public health department. I authorize my health care providers, including University Services, its physicians and its staff and the laboratories that run medical tests for me to use and/or disclose certain protected health information about me to New Century Labs, LLC for the purposes state below.
This authorization applies to the following protected health information about me: the laboratory requisition submitted by New Century Labs, LLC and the laboratory test values which are the result of the laboratory test(s) requested in the requisition. For avoidance of doubt, I specifically authorize the transfer of this information between and among me and the following Participants, organizations and their representatives: i) New Century Labs, LLC ii) University Services staff and physician of record, and iii) the reference laboratory of record. I understand that University Services physician of record may be required to receive my lab test results before I do, and that this physician’s authorization to release those results to New Century Labs, LLC may also be required before I receive my results.
The protected health information will be used or disclosed for the sole purpose of complying with the state and federal laws which may require a physician or their agent to: 1) review and approve a laboratory requisition; and 2) review the laboratory test results. This review may be conducted for any reason, including in the event laboratory values, which are outside of normal ranges, require the physician or its agent to contact me. The purposes outlined above are provided so that I can make an informed decision whether to allow release of the information to the parties referenced in this authorization. This authorization will expire one year after the date of this authorization. I understand that I have a right to receive a copy of this authorization. I understand that the sole purpose of the laboratory test is to generate the results of the tests that I and New Century Labs, LLC have requested, and the laboratory tests will not be requisitioned unless I sign this authorization. I have the right to refuse to agree to this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization have acted in reliance upon this authorization. My written revocation must be submitted to the NCL privacy officer. Patient Authorization for Use and Disclosure of Protected Health Information